Nokea
A nurse is caring for a client who is pregnant for the fourth time. The client delivered two full-term newborns and had one spontaneous abortion at 10 weeks of gestation. The nurse should document the client's obstetrical history as which of the following?
- A. Gravida 3, Para 2.
- B. Gravida 3, Para 3.
- C. Gravida 4, Para 2.
- D. Gravida 4, Para 3.
Correct Answer: C
Rationale: Gravida 4 reflects the client's total pregnancies, including the current one and her abortion, while Para 2 accounts for her two full-term live births, accurately documenting her obstetrical history.
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A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus flammeus.
- B. Caput succedaneum.
- C. Cephalohematoma.
- D. Erythema toxicum.
Correct Answer: B
Rationale: Caput succedaneum involves swelling of the scalp caused by pressure during delivery, often crossing suture lines due to subcutaneous fluid accumulation, a hallmark distinguishing it from other neonatal head conditions.
A nurse is providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include?
- A. Peanut butter sandwich.
- B. Sliced apples.
- C. Glass of skim milk.
- D. Scrambled egg.
Correct Answer: B
Rationale: Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
A nurse is caring for a client who is receiving oxytocin to augment labor. The client has an intrauterine pressure catheter and an internal fetal scalp electrode for monitoring. Which of the following is an indication that the nurse should discontinue the infusion?
- A. Contraction frequency every 3 minutes.
- B. Contraction duration of 100 seconds.
- C. Fetal heart rate of 118/min.
- D. Fetal heart rate with moderate variability.
Correct Answer: B
Rationale: Contraction duration of 100 seconds exceeds the normal range (usually less than 90 seconds), risking uterine hyperstimulation and fetal compromise, necessitating oxytocin discontinuation.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
- A. BUN level of 30 mg/dL (normal range: 10 to 20 mg/dL).
- B. Hemoglobin level of 9.9 g/dL (normal range: 11 to 16 g/dL).
- C. Serum uric acid level of 2.5 mg/dL (normal range: 2.7 to 7.3 mg/dL).
- D. Casual blood glucose level of 228 mg/dL (normal range: less than 200 mg/dL).
Correct Answer: A
Rationale: A BUN level of 30 mg/dL is above the normal range of 10 to 20 mg/dL. Elevated BUN is consistent with renal involvement in preeclampsia, which is caused by vascular constriction and reduced renal perfusion.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the necessary equipment to initiate an amnioinfusion.
- B. Assist with performing a vaginal/speculum exam to check for a prolapsed umbilical cord.
- C. Discontinue the infusion of oxytocin.
- D. Provide instructions for the client about potential preparation for birth.
Correct Answer: C
Rationale: Discontinuing oxytocin reduces uterine contractions, alleviating cord compression and improving fetal oxygenation, which is the first step in managing recurrent variable decelerations of fetal heart rate.